35Response to ROM No Capsular Pattern Is Flexion Limited? No YesIs there an opening Restriction?Assess and TxC-T and T jxnYesNoJoint Mobs for openingIs there a Closing Restriction?YesNoLikely a combined lesionJoint Mobs for closing

38Upper Thoracic ManipulationCT junctionPatient sits far back on tableStabilize shouldersUse their hands as fulcrumDistract upwardsDrop down

39Thoracic OutletClavicle, 1st Rib and Costoclavicular lig, subclavius and ant scaleneCompression of subclavian or axiallary artery, vein, or brachial plexius (C8 and T1)Costoclavicular syndromeLoss space between clavicle and 1st ribCervical Rib (<1%) syndromeCervical rib from C7 or band of fibrous tissue in area

55Injury in Manipulation82% were rotational manipulations66% had signs or symptoms of VBAAfter first manipulation78% had consequences of VB ischemia20 died42 had residual symptomsRisk for Mild complication 1 in 40,000Risk for Serious complication 1 in 1 million

60Treatment/ManipulationTo Open or Close?Force a stuck drawer closeOpen the drawer fully and then attempt to close it

61Cervical Manipulation ProcedurePosition patient comfortablyPalpate the cervical treatment levelFlex or Extend the neck until tension/approximation is noted at the spinal interspace above the desired levelRotate the head to end rangeDuring patient exhalation - stress end rangeQuickly overpress when the patient relaxesReassess the patient’s movement and record

63Alternative to ManipulationFollow the outlined treatment(no overpress)Oscillate the head at end rangeTraction (manual or mechanical)Soft tissue TreatmentModalitiesMassageSeek training with skilled manipulatorRefer patient to skilled manipulator

64Myth of Manipulation Manipulation is not Manipulation isDealing with dislocation/subluxationCorrecting a “little bone out of place”Restoring a “slipped disc”Manipulation isDesigned to overcome a motion restriction

78Outcomes Discharge: 8 of 11 (73%) were negative on cluster of tests2 had positive Spurling’s but improved function1 had ULTT and Suprling’s10 Patients (91%) had clinically meaningful reductions in pain and disability(> 2-7pt change)Lasted for 6 months-45 % had 10/1050% had mild limitations

79Expand CriteriaIf treatment aimed at thoracic helps with radiculopathy- how about neck pain?